Verruca vulgaris of the tongue: A case report with literature review

Abstract

Unlabelled:
Verruca vulgaris (common warts) is a benign lesion of skin and mucous membranes caused by human papillomavirus (HPV). The lesions are typically self-limited but may vary in size and number. The occurrence on the tongue is extremely rare. To the best of our knowledge, only one verruca vulgaris existing in the tongue had been reported in the literature.

Case presentation:
A rare case of verruca vulgaris of the tongue occurring in a 36-year-old Caucasian male is presented with a discussion on ethiopathogenesis and the treatment methods. Verruca vulgaris must be remembered in the differential diagnosis of tongue lesions and surgical treatment may provide satisfactory outcomes.

Full text

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INTRODUCTION
Verruca vulgaris (VV) is a frequent skin disease caused by
human papillomavirus (HPV) infection []. It is also known
as common warts and the lesion tends to affect epithelial tis-
sues and mucous membranes. Verruca vulgaris is a benign
epidermal proliferation with infrequent malignant change [].
e clinical presentations of verruca vulgaris vary according
to the viral type and the anatomical site infected. e benign
VV include squamous papilloma with verruca vulgaris, focal
epithelial hyperplasia and condyloma []. Verruca vulgaris is
most commonly induced by HPV-, HPV- or HPV- and it
rarely occurs on the tongue.
As a contagious disorder, it could be transmitted to other
areas of body if left unattended. Compared to the commonly
affected sites, such as hands, feet or face, the verruca involving
the tongue has rarely been reported in the English literature.
Several treatments including surgery, cryotherapy, electrocauter-
ization, laser or topical agents all focus on eradicating the lesions;
however, the treatment strategy can vary depending on the dis-
ease location, severity, and the patient’s immune status [].
In this case report, a rare case of verruca vulgaris on the
tongue is presented along with a brief review of literature.
CASE PRESENTATION
A -year-old male was admitted to the outpatient clinic of
the otolaryngology department of our tertiary care center. He
had been complaining of a painless, exophytic, sessile mass of
×cm on the dorsal surface of the tongue (Figure ). e patient
did not have any verrucas elsewhere in the body. Under local
anesthesia, the lesion was excised totally using needle-tip elec-
trocautery with preservation of safe surgical margins. Diagnosis
of verruca vulgaris was confirmed by pathological investigation
(Figure ) and polymerase chain reaction analysis which revealed
HPV- DNA. No recurrences or complications had been noted
in the observed on follow-up period of  months.
DISCUSSION
Verruca vulgaris (benign cutaneous wart) is a common der-
matose of viral origin affecting  to  of the general popula-
tion with a peak incidence between the ages of and years [].
ey can affect the patient’s quality of life causing discomfort,
embarrassment and fear of negative appraisal in the society. e
lesions are caused by human papillomavirus (HPV) invading
epithelial cells with consequent cell proliferation and nodule/
plaque formation. ey usually occur in wet and macerated
skin areas of the body that touch rough surfaces []. e lesions
* Corresponding author: Ahmet Ural,
Department of Otorhinolaryngology, Karadeniz Technical University
School of Medicine, 61080 Trabzon TURKEY
Tel: 00904623775884
Fax: 00904623250518
E-mail: ahmetural2001@yahoo.com
Submitted: 10 May 2014 / Accepted: 07 July 2014
Verruca vulgaris of the tongue: a case report
withliterature review
Ahmet Ural1*, Selçuk Arslan1, Şafak Ersöz2, Betül Değer1
¹Department of Otorhinolaryngology, Karadeniz Technical University School of Medicine, Trabzon, Turkey. 2Department of Pathology,
Karadeniz Technical University School of Medicine, Trabzon, Turkey.
Abstract
Verruca vulgaris (common warts) is a benign lesion of skin and mucous membranes caused by human papillomovirus (HPV). e lesions
are typically self-limited but may vary in size and number. e occurrence on the tongue is extremely rare. To the best of our knowledge, only
one verruca vulgaris existing in the tongue had been reported in the literature. Case presentation: A rare case of verruca vulgaris of the tongue
occurring in a -year-old Caucasian male is presented with a discussion on ethiopathogenesis and the treatment methods. Verruca vulgaris
must be remembered in the differential diagnosis of tongue lesions and surgical treatment may provide satisfactory outcomes.
KEY WORDS: verruca vulgaris, tongue, human papillomavirus
Bosn J Basic Med Sci. 2014;14(3):136-138. © 2014 ABMSFBIH

137
Ahmet Ural et al.: Verruca vulgaris of the tongue: a case report with literature review
are usually located on hands, fingers, knees and elbows but can
be found on any other site of body. e minor abrasions in the
macerated skin are the sites of entry of HPV to basal keratino-
cytes of the epithelium. e warts can be transmitted by direct
or indirect contact and once the skin is infected autoinoculation
to secondary sites can occur by scratching, shaving or trauma-
tizing the skin []. A strong immune response is not created
by the viral agent and the lesion is self-limited allowing a silent
growth for months or even years. Warts can resolve sponta-
neously depending on the host immune status and the type of
the virus. Approximately  of the lesions show spontaneous
regression in  months and  and  to  regress sponta-
neously within  months and years respectively []. However,
some lesions may grow in size and number, and even become
increasingly resistant to treatment over time [].
Human papillomavirus is a double-stranded DNA virus
that causes common warts found on the skin and anogen-
ital warts (condyloma acuminatum) located on the genita-
lia. Currently, more than  genotypically different forms
of HPV have been identified according to DNA studies and
type-specific antibodies against capsid antigens []. Verruca
vulgaris (common warts) on the hands and feet are caused by
HPV types , , , ,  and . Types  and  are implicated
in the etiology of anogenital warts, and types , , , , are
associated with cervix carcinoma []. Infection with multiple
types is not uncommon and different HPV types can show syn-
ergistic effect to facilitate a concurrent infection with another
type or act antagonistically to interfere with one another [].
Certain types of HPV are epitheliotropic and invade cornified
squamous epithelium while some other mucosotropic types
show preference for uncornified mucous membranes.
e benign HPV-associated oral lesions, focal epithelial
hyperplasia (Heck disease), oral squamous cell papilloma, oral
verruca vulgaris (common wart) and oral condyloma acumina-
tum, are collectively referred to as oral warts. e m ajority of cases
reported in the literature regarding to warts of the tongue and oral
cavity include condyloma acuminatum caused by HPV types 
and , ,  []. Oral condyloma acuminatum (veneral wart)
is a sexually transmitted disease which is strongly associated with
oro-genital sexual behavior. e incidence has increased consid-
erably due to the changes in sexual behaviour and an increase
in the practice of oral sex []. In contrast, oral verruca vulgaris
lesions caused by HPV types , , ,  as in the current case are
rarer with one reported case of VV of the tongue []. e lesions
are usually caused by autoinoculation from lesions on the fingers
and hands mainly in the children []. In our case, no additional
risk factors such as history of common shower use or presence of
other foci of verrucous lesions could be detected.
Focal epithelial hyperplasia, oral squamous papilloma, oral
lichen planus, oral leukoplakia, oral verrucous carcinoma and
oral squamous carcinoma should be considered in the differ-
ential diagnosis of VV. Focal epithelial hyperplasia affects oral
mucosa, lips, tongue, notably lower lip and more rarely the pal-
ate and it is strongly associated with HPV types  and  [].
Oral squamous papilloma is related to HPV  and  and is seen
in oral mucosa over soft palate, lingual, frenulum, lower lip and
uvula among adults []. Oral lichen planus is found predomi-
nantly in females between the ages of  to  years. e lesions
are generally bilateral and symmetrical, affects the oral mucosa,
gingival, the dorsum of tongue and lipmucosa. HPV types 
and  are commonly found in about  of patients []. HPV
Figure 1. White verrucous lesion on the right side of the tongue
Figure 2. Histopathologic characteristics of the lesion.
(a) Polypoid mass with an epithelium displaying acanthosis, par-
akeratosis and papillomatosis. (b) Superficial layers of the epithe-
lium demonstrate koilocytotic changes
b
a

Ahmet Ural et al.: Verruca vulgaris of the tongue: a case report with literature review
138
types ,  and  commonly cause oral leukoplakia, a premalig-
nant lesion of oral mucosa seen as white patches or plaques [].
Different treatment methods are available for VV at pres-
ent, but none is proven to be universally effective. Topical
agents like salicylic acid and cantharidi may have only mod-
erate beneficial effect compared to placebo, though they had
been used very commonly by the public even without pre-
scriptions. ese corrosive topical agents should not be used
by patients themselves theoretically, because it is difficult for
them to judge the depth of lesion and dermal condition, which
may increase the possibility of tissue damage and unhealing [].
Surgical excision is a widely practiced method of treatment.
Success rates of  to  have been reported but scarring
can be problematic on the sole of foot and face [].
CONCLUSION
In conclusion, verruca vulgaris is a rare pathology of
tongue that can be treated effectively with surgical excision.
Other possible foci must be carefully investigated for eradica-
tion of disease completely.
CONSENT
Written consent has been obtained from the patient for
publication of this case report.
DECLARATION OF INTEREST
e authors declare no competing interests.
ACKNOWLEDGEMENTS
No financial support was received for this paper.
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